Evidence should guide policyDr KC’s demand to open medical colleges in rural regions is impractical to fulfil
Nepal is in the process of finalising the National Medical Education Bill through Parliament. The government has tabled the draft Medical Education Ordinance Replacement Bill in Parliament to replace the bill brought through a presidential ordinance which was drafted based on the report of the Mathema Commission for Medical Education Reform. The government has changed some of the provisions in the bill brought through the Presidential ordinance. Dr Govinda KC is on a hunger strike demanding that the government not make any changes in the bill. The Mathema Commission’s report has many good suggestions, but it also has limitations and gaps, especially with regard to the health workforce.
Inaccurate and inconsistent
Though the principle and approach used for the projection of the need and availability of doctors, nurses and midwives looks fine, there are inaccuracies and inconsistencies while calculating the number of doctors. The Mathema Commission has considered the number of doctors registered at the Nepal Medical Council (NMC) to estimate the number of doctors currently available. According to the NMC, 15,666 doctors were registered as of 2015. The commission has estimated that there will be 54,666 doctors available in the country by 2031 against the need forecast of 35,000, which means a surplus of 19,666 doctors.
However, the NMC figure also includes dental doctors (BDS). So the number should be 12,332 doctors after deducting 20 percent from the total to exclude dental doctors. Similarly, the NMC registered number includes doctors who are out of the country. It is fair to consider that 25 percent of the doctors are based abroad. So the number of medical doctors available would be around 9,400, not 15,666 as mentioned in the report.
The report predicts that 32,000 doctors will be produced from the existing medical colleges between 2016 and 2031 which is a gross over-estimation. According to NMC records, the total number of NMC registered doctors including BDS as of mid-2018 was 20,387. Between 2015 and mid-2018, there were 4,721 new NMC registrations which means 1,888 per year including BDS. Between 2012 and 2015, there were 5,472 NMC registrations or 1,824 per year. So the number of doctors produced effectively each year in the country is 1,510. If we exclude doctors based abroad, the net number of doctors available in the country is 1,133 per year. At this rate, the estimated number of doctors available in 2031 will be 27,528, not 54,666 as stated in the report. Similarly, the estimated number of doctors currently available in the country is 12,232.
Likewise, the international standard of 23 skilled health workers (doctors, nurses and midwives) per 10,000 population which the Mathema Commission used to forecast the need for skilled health workers has become outdated. The World Health Organisation now recommends 44.5 skilled health workers per 10,000 population to achieve the Sustainable Development Goals (SDGs).
Nepal is aiming to attain universal health coverage by 2030 under the SDG framework, so it is very important to use this new international benchmark to estimate the future needs of doctors, nurses and midwives. Nepal’s population is projected to reach 35.5 million by 2031, and there will be a need for 44,730 doctors then. As per the current supply trend, we can add 14,729 doctors in the next 13 years. Nepal will have 26,961 doctors by 2031, which means a deficit of 17,769 doctors.
Not so pragmatic
We want the government to make the necessary investments and take the responsibility to produce the required number of skilled health workers and expand the hospital and health services. But it is impossible for the government to invest huge resources. So, we need to learn from the past and incorporate the lessons when planning for the future. Nepal has increased the production of doctors and other skilled health workers in the 15 years between 2001 and 2015. We need to make another big jump in health gains to achieve universal health coverage by 2030 under the SDG framework. We need to fill the huge gaps as mentioned above in the availability and quality of doctors and other health workers and hospital beds and other facilities.
Certainly, there are many issues and wrongdoings in the private health sector including medical education. It is the government’s responsibility to regulate them properly. It should investigate the details and take necessary action against those that are not performing well or are involved in wrongdoing. Simply blaming the whole sector and individuals with the label of ‘mafia’ won’t lead us to a solution. Therefore, the National Medical Education Bill should not be restrictive at least for the time being with regard to new medical colleges. The 10-year moratorium on opening new medical colleges in the Kathmandu Valley as recommended by the Mathema Commission is inappropriate.
Dr KC’s demand that medical colleges be opened in rural areas is impractical to fulfil for the private sector. However, to ensure that they contribute to the expansion of health services in rural areas, the government can assign a number of rural districts to each medical college where they will manage or support the district hospital and district health system including community level health interventions. This can provide medical students a very good learning ground across the whole spectrum from community to tertiary level health care delivery processes.
There is great demand for medical education. Providing medical education in the country will prevent a big outflow of foreign currency caused by students travelling abroad to study which, according to the Mathema Commission, number 500-700 annually. The quality of medical graduates from abroad is always in question in society. Their pass rate in the NMC licensing exam is much lower than those who have graduated from domestic medical colleges. Surprisingly, Dr KC’s quality concern does not see them; we have not heard him and his supporters making any mention of these issues.
Marahatta is a member of the High Level Commission for Formulation of Education Policy. Tamang is a public health practitioner